Basic Surgery (100q).1

Lean body mass increases.

Total body water increases.

Adipose tissue decreases.

Body weight decreases.

Hypermetabolism.

Fever

Tachypnea

Hyperphagia

Negative nitrogen balance.

Hypotension

Hypoperfusion of tissues.

Hypoxemia

All of the above.

Cytokines act directly on target cells and may potentiate the actions of one another.

Interleukin 1 (IL-1) is a major proinflammatory mediator with multiple effects, including regulation of skeletal muscle proteolysis in patients with sepsis or significant injury.

Platelet-activating factor (PAF) is a major cytokine that results in platelet aggregation, bronchoconstriction, and increased vascular permeability.

Tumor necrosis factor alpha (TNF-a), despite its short plasma half-life, appears to be a principal mediator in the evolution of sepsis and the multiple organ dysfunction syndrome because of its multiple actions and the secondary cascades that it stimulates

There is a decrease in systemic vascular resistance and an increase in venous capacitance.

Tachycardia or bradycardia may be observed, along with hypotension.

The use of an alpha agonist such as phenylephrine is the mainstay of treatment

Severe head injury, spinal cord injury, and high spinal anesthesia may all cause neurogenic shock.

Dobutamine

Sodium nitroprusside.

Pneumatic antishock garment.

Intra-aortic balloon pump

There are no primary alterations in cardiovascular signs

Signs of increased intracranial pressure may be masked by the hyponatremia.

Oliguric renal failure is an unlikely complication

Rapid correction of the hyponatremia may prevent central pontine injury

This patient is best treated by restriction of water intake.

The total extracellular fluid volume represents 40% of the body weight.

The plasma volume constitutes one fourth of the total extracellular fluid volume

Potassium is the principal cation in extracellular fluid.

The protein content of the plasma produces a lower concentration of cations than in the interstitial fluid

The interstitial fluid equilibrates slowly with the other body compartments.

The sodium concentration must be corrected by 5 mEq. per 100 mg. per 100 ml. elevation in blood glucose.

With normal renal function, this patient is likely to be volume overloaded.

Proper fluid therapy would be unlikely to include potassium administration

Insulin administration will increase the potassium content of cells.

Early in treatment adequate urine output is a reliable measure of adequate volume resuscitation.

Age over 70 years.

Chronic malnutrition.

Controlled diabetes mellitus.

Long-term steroid use.

Infection at a remote body site.

Myocardial infarct 4 months previously.

Clinical evidence of congestive heart failure in a patient with 8.5 gm. per dl. hemoglobin.

Premature atrial or ventricular contractions on electrocardiogram

A harsh aortic systolic murmur.

Age over 70 years.

Whole blood is the most commonly used red cell preparation for transfusion in the United States.

Whole blood is effective in the replacement of acute blood loss.

Most blood banks in the United States have large supplies of whole blood available.

The use of whole blood produces higher rates of disease transmission than the use of individual component therapies

Packed red blood cells and crystalloid solution should be infused to restore oxygen-carrying capacity and intravascular volume.

Two units of FFP should be given with every 5 units of packed red blood cells in most cases

A “six pack” of platelets should be administered with every 10 units of packed red blood cells in most cases.

One to two ampules of sodium bicarbonate should be administered with every 5 units of packed red blood cells to avoid acidosis.

One ampule of calcium chloride should be administered with every 5 units of packed red blood cells to avoid hypocalcemia.

History and physical examination.

Complete blood count (CBC), including platelet count

Prothrombin time (PT) and activated partial thromboplastin time (APTT).

Studies of platelet aggregation with adenosine diphosphate (ADP) and epinephrine

An allergic reaction.

An anaphylactoid reaction.

A clerical error.

An acute bacterial infection transmitted in blood.

This formulation is proposed for the use of patients with fulminant hepatitis

Nitrogen balance is achieved in such patients with amounts of 40 gm. of amino acids per 24 hours.

The use of 80 to 100 gm. of such solutions is associated with hepatic encephalopathy

In some studies of surgical patients, improvements in mortality have been reported.

Nutritional support benefits the patient's lean body mass but does not enable the tumor to grow

In experimental animals, the growth of implanted tumors is directly proportional to the amount of calories and protein supplied.

Prospective randomized trials of nutritional support utilizing chemotherapy and radiation therapy have revealed benefits to patients receiving total parenteral nutrition

Studies of nutritional support for patients with cancer about to undergo surgery revealed decreased morbidity and mortality, especially morbidity from sepsis.

In patients with respiratory insufficiency, administration of glucose as a principal calorie source is contraindicated

In patients with pulmonary infection and sepsis, calorie support should consist of 95% fat and 5% glucose.

In Askanazi's study, increased CO 2 production and difficulty in weaning was associated only with pronounced overfeeding.

CO 2 production should be measured in most patients who are supported by respirators in intensive care units and are receiving nutritional support

Gallstones occur with the same frequency in diabetes patients as in the healthy population.

The presence of gallstones, regardless of the presence of symptoms, is an indication for cholecystectomy in a diabetes patient.

Diabetes patients with gallstones and chronic biliary pain should be managed nonoperatively with chemical dissolution and/or lithotripsy because of severe complicating medical conditions and a high operative risk.

The presence of diabetes and gallstones places the patient at high risk for pancreatic cancer.

Diabetes patients with symptomatic gallstones should have prompt elective cholecystectomy, to avoid the complications of acute cholecystitis and gallbladder necrosis.

Prevents the aggressive development of atherosclerosis in diabetic patients

Is not associated with unawareness of hypoglycemia.

Improves peripheral neuropathy

Improves established retinopathy and nephropathy

Is indicated in all patients with non–insulin-dependent diabetes mellitus (NIDDM).

The surgical procedure.

The length of the surgical procedure.

The anesthetic technique (e.g., general, regional).

The length of anesthesia.

All of the above.

Earlier mobilization after surgery.

Earlier return of bowel function.

Shorter hospitalizations.

Decreased stress response to surgery.

All of the above

Protein depletion.

Infection

Anemia

Advanced age.

Hypoxia

Phagocytosis is a mechanistically distinct process of endocytosis performed by special cells to take up larger particles such as bacteria or erythrocytes

Lymphocytes are the primary blood cell involved with this process

The process involves a coating of the cytoplasmic surface known as clathrin

Phagocytosis is performed only by white blood cells and tissue macrophages

The cell membrane is able to maintain a 10,000 fold gradient between the extracellular concentration of ionized calcium and the intracellular concentration

The key to these differences is the fact that the plasma membrane is normally impermeable to sodium, potassium and calcium

The selectivity of biologic membranes is highly consistent and seldom changes

The selectivity of cell membranes relates only to ions and not organic compounds

DNA is contained only in the nucleus of the cell

DNA strands are encoded by the sequence of four bases—adenine, guanine, cytosine and uridine

The basic unit of information of DNA is the intron, a sequence of three bases

There are an infinite number of possible codons

The first step in gene transcription involves separating the double helix of DNA by an enzyme known as DNA polymerase

The initial product of DNA transcription is called heterogeneous nuclear RNA which codes directly for proteins

After processing is complete, the mRNA is exported from the nucleus to the cytoplasm

Only one protein can be produced from an initial mRNA strand

The goal of nutritional support is maintenance of body cell mass and limitation of weight loss to less than 25% of preinjury weight

Under-nutrition may compromise the patient’s available defense mechanisms

Nutritional support is an immediate priority for the trauma patient

Fifty percent of non-nitrogen caloric requirements should be provided in the form of fat

Preoperative nutritional support should be provided to all patients with cancer

To be effective, preoperative nutrition must be given for at least two weeks preoperatively

Parenteral nutrition is the preferred route of feeding for all cancer patients

Standard total parenteral nutrition solutions maintain integrity of the small bowel

None of the above

Concentrations of glucose no higher than 5% should be used to avoid peripheral vein sclerosis

A major disadvantage of the peripheral technique is limited caloric delivery

If total parenteral nutrition is required, access to the superior vena cava via the external jugular vein is the most suitable site

Venous thrombosis is an uncommon complication for long-term central vein catheterization

Glutamine is an essential amino acid

Glutamine appears to be of primary benefit in critical illness

Glutamine is included in most standard TPN solutions

Glutamine is the primary energy source for intestinal mucosal cells of the small bowel and colon

Since the patient’s weight had been stable with no preoperative nutritional deficit, 5% dextrose intravenous solutions are adequate for the initial postoperative source of nutrition

Preoperative immunologic status should be determined including total peripheral lymphocyte count and delayed hypersensitivity reaction to determine skin-test response to common antigens

Routine postoperative fluid administration with intravenous 5% glucose solutions can provide the calories to meet basal energy requirements

A jejunal feeding catheter should be placed at the time of surgery for postoperative enteral feeding

A wet-to-dry dressing is the most optimal form of wound management

A moist occlusive dressing promotes epithelialization and reduces pain

The protein rich plasma exudate covering the open wound facilitates healing

Irrigation of the wound disrupts epithelialization therefore inhibiting the healing process

Frequent surgical debridement is usually necessary

Water irrigation can effectively debride most wounds

Hydrogen peroxide is particularly useful in the management of open wounds

A number of the newer dressing products have clearly been shown to promote wound healing compared to simple moist occlusive dressing

Systemic antibiotics are indicated for all open wounds

Bacterial resistance can occur with systemic but not topical antibiotics

An indication for systemic antibiotic administration is a granulation tissue bacterial count in excess of greater than 105 organisms/gram of tissue on quantitative analysis

Silver sulfadiazine is useful only for the management of burns

Liver

Skin

Bone

Muscle

Vitamin A supplementation

Vitamin C supplementation

Vitamin E application to the wound

Zinc supplementation

None of the above

Keloids occur randomly regardless of gender or race

Hypertrophic scars and keloid are histologically different

Keloids tend to develop early and hypertrophic scars late after the surgical injury

Simple reexcision and closure of a hypertrophic scar can be useful in certain situations such as a wound closed by secondary intention

Vasoconstriction is an early event in the response to injury

Vasodilatation is a detrimental response to injury with normal body processes working to avoid this process

Vascular permeability is maintained to prevent further cellular injury

Histamine, prostaglandin E2 (PGE2) and prostacyclin (PGI2) are important mediators of local vasoconstriction

Careful monitoring of prothrombin time and aPTT time are necessary to avoid bleeding complications

A level of serum fibrinogen less than 100 mg/dl is associated with an increased risk of bleeding

Recent (less than 10 days) major surgery is a contraindication to systemic but not regional fibrinolytic therapy

A patient with a cerebrovascular event occurring less than two months ago can be treated with fibrinolytic therapy if head CT scan is normal

While IL-1 and TNFa share many biologic effects, IL-1 appears to be more potent

IL-1 expression is in part autoregulated

IL-1 inhibits prostaglandin production

The ability of IL-1 to upregulate endothelial cell-neutrophil adhesion molecules is relatively limited

All antibodies are composed of one type of heavy and one type of light protein chain

The carboxyl terminus of the heavy chain is the antigen binding site

Antibody of the immunoglobulin G class is the initial antibody produced in response to an antigenic stimulus

Immunoglobulins A, D, and E play an active role in the circulating humoral response

The issue of toxic side effects of antibiotics is only important in dealing with emperic therapy

Single agent therapy is generally inferior to specific multi-drug therapy (aminoglycoside plus an antianaerobic agent) for the treatment of secondary bacterial peritonitis due to appendicitis, diverticulitis, penetrating gastrointestinal injury, or anastomotic leak

With the empiric use of antibiotics, a diligent search for the septic source should be undertaken and continued until identified

In clinical situations in which polymicrobial infection is identified, specifically-directed treatment for the predominant organism is satisfactory

Cytokines are produced solely by macrophages

Cytokines act only on other cells within the same local environment

Cytokines may have both protective and deleterious effects on the host

Each specific cytokine is produced by a single cell type

The appropriate use of prophylactic antibiotics must include the initiation of the agent prior to the surgical procedure

Continuing the antibiotic into the postoperative period has led to improved results in antibiotic prophylaxis

The prophylactic administration of broad-spectrum agents (third-generation cephalosporins) has been shown to be particularly advantageous

The topical use of antimicrobial agents is of no advantage in the prophylactic setting

Gut decontamination

Anti-LPS antibody

Anti-TNF antibody

Thymopentin

None of the above

A fall in hematocrit or hemoglobin always accompanies hemorrhagic shock

The treatment of shock is generic regardless of the etiology

Pharmacologic intervention to increase myocardial contractility in hypovolemic shock is an important part the early management

Complications are less frequent after treatment of hemorrhagic shock than septic or traumatic shock

The patient likely is suffering from hypovolemic shock and should respond quickly to fluid resuscitation

Beck’s triad will likely be an obvious indication of compressive cardiogenic shock due to pericardial tamponade

Echocardiography is the most sensitive noninvasive approach for diagnosis of pericardial tamponade

The placement of bilateral chest tubes will likely resolve the problem

The low blood pressure can be assumed to be due to neurogenic shock

The sole cause of hypotension is the loss of sympathetic input to the venous system

Despite significant hypotension, secondary organ injury will be uncommon

There is no role for pharmacologic intervention to maintain blood pressure

The clinical picture of gram negative septic shock is specifically different than shock associated with other infectious agents

The circulatory derangements of septic shock precede the development of metabolic abnormalities

Splanchnic vascular resistance falls in similar fashion to overall systemic vascular resistance

Despite normal mechanisms of intrinsic expansion of the circulating blood volume, exogenous volume resuscitation is necessary